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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. J !, ) FOR OFFICE USE: APPLICATION !G7 q/ ' )r Non•Transle,rable, Revocable, Suspendable) ENVIRONMENTPUMP&WELL AL HEALTH PERMIT' ". (COMPLETE IN TRIPLICATE) WATER QUALITY" Application ispereby made to the San Joaquin Local Health District fore permit to construct and/or install the work herein described.This appli tion is made in com llance with San Joaquin County Ordtr trancery/o. 1 /6_2an�d the rules and regulations of the San Joaquin Local Healih District. Exact Site Ac�lress .�/t7�"r'S� - 5�03�1LG >Z'//C ��dr, City/Town, Ili _ Owner's Name Phone 122- Address - City iL Contractor's Name License If 224&3 Business Phone`SS��//AS Contractor's Address ,d5�Emergency Phone Is Certificate of Workman's Compensation In urance on File.With SJLHD? Yes X - No TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ _ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT P OTHER 0 PUMP INSTALLATION❑ PUMP REPAIR 11 t REPLACEMENT❑ . • . 1 r DISTANCE TO NEAREST: Septic Tank Sewer Lines_ Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well C INTENDED USE TYPE Of WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation IQ DOMESTIC/PRIVATE ', ❑ DRILLED y' Dia. of Well Casing ❑ DOMESTIC/PUBLIC �❑3 DRIVEN .Gauge of Casing AID �r ❑ IRRIGATION 1r GRAVItL P!CK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ��fl(Lrs 7(" (d ❑ DISPOSAL ❑ OTHER _ Other Information _54f ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor, A Type of Pbmp - H.P. PUMP REPLACEMENT: 11 State Work Done ' PUMP REPAIR: ❑ Stale WOrk Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure z I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall:not employ any.person in such (hanner as to become subject to workman's compensation laws of California." � Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persc�s subject to workman s compensation laws of California." I]wi c�`a�'l'lr/fforr'�aG�roouutt Inspe on prior,to groutin and a final inspection. Signed X�y�•� C V Title: -LC V Date: on t%O O � (Draw t Plan on Reverse Side) • trt,`,y'\ �(\�� FOR DEPARTMENT.USEIONLY p PHASE.tWa1� 1 W19.� O� �A O I Application Accepted By Date Additional Comments: .Phe I rout Inspection qy Phase III Final Inspection Inspection By� Date 7�/.'7 Inspection By�.e/�.. — Date Fee IS Due: ❑ ANNUALLYPER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 It Received By January 31 J ❑ July 1 &Received By July 31 REMIT BASE ExPLANATIOII BILLING. REMITTANCE s AMOUNT DUE CHECKED DATE ,DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER _i t OTHER <Zk tq -S1 -- I" I t o 39 Received by Dale Raccipt No. Permll No Issuance Dale Mailed, Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON,CA 95MI